ENDOMETRIOSIS AS A COMMON CAUSE OF PELVIC PAIN M.Basta Nikolić, S. Stojanović, O. Nikolić, T. Mrđanin, D. Donat, V. Žigić Center for Radiology, Clinical Center of Vojvodina Novi Sad
Chronic pelvic pain (CPP) Presence of pain >6m localized to the anatomic pelvis Severe enough to cause functional disability and require medical or surgical treatment Cause of ~40% laparoscopies and 10-15% hysterectomies
CAUSE OF CPP 1. Gyn and Obs 1/3 endometriosis 2. Urologic 3. GI 4. Vascular 1/3 adhesions 5. MS 6. Neuro 7. Psychological Neis KJ,Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist s and an endoscopist s point of view. Gynecol Endocrinol.2009;25(11):757-761.
ENDOMETRIOSIS -presence of functional endometrial glands and stroma outside the uterine cavity
SYMPTOMS Infertility pelvic pain Unusual symptoms gastrointestinal involvement: catamenialdiarrhoea, rectal bleeding and constipation vesical involvement: urgency, frequency, haematuria thoracic involvement: pleuriticchest pain, pneumothorax, pleural effusions or cyclic haemoptysis asymptomatic: especially if disease is isolated to the peritoneum
AETHIOPATHOGENETIC MECHANISMS OF ENDOMETRIOSIS-ASSOCIATED CPP Nociceptive Inflammatory Neuropathic mechanisms
PATHOGENESIS metastatic theory metaplastic theory induction theory radiopedia.org
PREVALENCE 1 in 10 women Strongly linked to infertility 25-50% of infertile women have endometriosis 30-50% of women with endometriosis is infertile
LOCATION OVARIAN SUPERFICIAL DEEP
SUPERFICIAL ENDOMETRIOSIS superficial plaques scattered across the peritoneum, ovaries and uterine ligaments DEEP PELVIC ENDOMETROSIS subperitonealinvasion by endometrioticlesions that exceeds 5 mm in depth and comprises nodules, cysts and secondary scarring Antônio Coutinho, et al. MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay RadioGraphics 2011 31:2, 549-567
LOCATION Most common: ovaries, pelvis, peritoneum Less common: C section scar, deep subperitoneal tissue, GI tract, bladder, chest, subcutaneous tissue Most common sites of pelvic involvement: Douglas pouch, uterosacral ligaments and torus uterinus
IMAGING ULTRASOUND TRANSABDOMINAL TRANSVAGINAL TRANSRECTAL MRI CT CLASSIC RADIOLOGICAL METHODS COLONOGRAPHY, ENTEROCLISIS, CHEST X RAY...
ENDOMETRIOSIS TRANSVAGINAL US OVARIES URINARY BLADDER TRANSRECTAL US RECTOVAGINAL UTEROSACRAL RECTOSYGMOID BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.
ULTRASONOGRAPHY Good for endometriomas Homogenous hypoechoic lesion No Doppler signal Unilocular May be multiple Poor for peritoneal implants
ENDOMETRIOMA CHOCOLATE CYST TRANSVAGINAL US MACROSCOPICALLY
THICK SEPTATIONS TRANSVAGINAL US MACROSCOPICALLY
MRI METHOD OF CHOICE! T1 T2 hyperintense high SI T1 FS hypointense-shading sign T2 dark spot sign DWI T1C+ variable restricted diffusion may have wall enhancement the presence of an enhancing mural nodule is suggestive of malignant transformation radiopaedia.org
MRI CHARACTERISTICS OF haemorrhagic powder burn lesions appear bright on T1 fat saturated sequences small solid deep lesions may be hyperintenseon T1 and hypointenseon T2 adhesions and fibrosis ENDOMETRIOSIS
uterosacral involvement irregular margins asymmetry nodularity and thickening altered T2 signal: isointense (50%), hypointense (40%) or hyperintense (10%) cf. myometrium vaginal involvement loss of hypointensesignal of posterior vaginal wall on T2WI thickening, nodules and/or masses
M Bazot et al. Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis. Human reproduction, 2007; 22:. 1457-63.
BLEEDING FOCI IN VAGINA
Pouch of Douglas Rectovaginal septum partial to complete obliteration suspended or lateralised fluid collections nodules or masses that passed through the lower border of the posterior lip of the cervix
Gastrointestinal tract Urinary tract rectal wall thickening anterior displacement of the rectum abnormal angulation loss of fat plane between uterus and bowel inflammatory response due to repeated haemorrhagecan lead to adhesions, strictures and bowel obstruction bladder localisedor diffuse bladder wall thickening signal intensity abnormality, nodules or masses usually located at the level of the vesicouterine pouch involvement of bladder mucosa is rare
KISSING OVARIES
chest catamenialpneumothorax haemothorax lung nodules cutaneous tissues nodules malignant transformation solid enhancing components
PULMONARY ENDOMETRIOSIS- CATAMENIAL SY CHEST X RAY THORACICCT
ENDOMETRIOSIS OF ANTERIOR ABDOMINAL WALL US CONTRAST CT
Hematosalpinx
Hydrosalpinx
ENDOMETRIOSIS ACCURACY OFMRI IN DIFFERENT LOCALIZATIONS 1 SENSITIVITY SPECIFICITY UTEROSACRAL LIGAMENT 86 % 77 % VAGINA 80 % 93% RECTOVAGINAL SEPTUM 80 % 97 % BOWEL 88 % 98 % 1. BAZOT M ET AL.; DEEP PELVIC ENDOMETRIOSIS: MR IMAGING FOR DIAGNOSIS AND PREDICTION OF EXTENSION OF DISEASE; RADIOLOGY 2004.
LIMITATIONS OFMRI EXAMINATION VISUALIZATION OF SMALL PERITONEAL IMPLANTS VISUALIZATION OF ADHESIONS 1. DIRECT PRESENCE OF FLUID ON BOTH SIDES 2. INDIRECT -ANGULATION OF BOWEL LOOPS -ELEVATION OF POSTERIOR VAGINAL FORNIX -CHANGE OF UTERUS AND OVARIES POSITION -TRIANGULAR PULLING OF ANTERIOR RECTAL WALL
LAPAROSCOPY-GOLDEN STRANDARD!
Total rate of recurrence of endometriosis after operative treatment is: 30-40% Paolo Vercellini Surgery for endometriosis-associated infertility: a pragmatic approach. Human Reproduction, Vol.24, No.2 pp. 254 269, 2009. 12/7/2017 41
PROBLEMS Up to 10 years for diagnosis!!! Every woman who has endometriosis knows another one with the same problem. Every doctor has different opinion and advice. However, satisfactory treatment is still a distant dream for many patients!
What to say? Sometimes difficult to diagnose Right choice of therapy -does it exist? Find a way to send them to someone else Remember one among all colleagues who you do not like
ENHANCEMENT OFMRI EXAMINATION ADDITIONAL SEQUENCES 1. FAT SUPPRESSED 2. GRADIENT ECHO 3. SUSCEPTIBILITY WEIGHTED 1 : 93% SENSITIVITY 100 % SPECIFICITY INTRAVAGINALLY- US GELLY INTRARECTAL- CONTRAST OR WATER INTRAMUSCULAR ANTIPERISTALTIC AGENS 1. TAKEUCHI ET AL.; SUSCEPTIBILITY WEIGHTEDMRI OF ENDOMETRIOMA: PRELIMINARY RESULTS; AJR 2008.
Ten Imaging Pearls 1. Multiple T1-Hyperintenseadnexal cysts are specific for endometriomas 2. Female pelvis MR imaging protocols should include T1-weighted Fat-suppressed sequences 3. Low SI of adnexal masses on STIR MR images is not specific for mature cystic teratomaand does not exclude endometrioma MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675 1691
4. Benign endometriomas show restricted diffusion 5. Hematosalpinxshould be considered specific for pelvic endometriosis 6. Obstruction of antegrademenstrual flow increases the risk for endometriosis 7. Decidualizedendometriosis may mimic ovarian malignancy in pregnant women MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675 1691
8. Endometriomascan transform into clear cell or endometrioid epithelial ovarian carcinomas 9. Solid fibrotic masses of endometriosis are common and easily overlooked 10. Solid invasive endometriosis of the posterior uterus can mimic posterior segmental adenomyosis MR Imaging of Endometriosis: Ten Imaging Pearls. RadioGraphics 2012; 32:1675 1691
CONCLUSION Consider endometriosis in the presence of gynecological symptomssuch as dysmenorrhoea,pelvic pain, dispareunia, infertility and fatigue in the presence of any of the above Or in women of reproductive age with non-gynecological cyclical symptoms (dyschezia,dysuria, haematuria, rectal bleeding, shoulder pain) MR is the imaging method of choice Laparoscopy is the golden standard of both diagnosis and treatment G.A.J. Dunselman et al. ESHRE guideline: management of women with endometriosis, Human Reproduction, 2014; 29 (3): 400 412.